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Which of the following nurse statements is completed in the working phase of the nurse-client relationship?
- A. Tell me about your religious beliefs during this season of the year.
- B. I will put a chair in the bathroom so you can begin personal care. I will return to assist you as needed.
- C. I understand that you are feeling anxious about going home. Let me assess you before we talk.
- D. Let's talk about a way to assist you to a standing position so you can walk in the hall.
Correct Answer: B
Rationale: During the working phase of the nurse-client relationship, the nurse and the client puts the mutually developed plan into action. Each person shares in performing the task that leads to the desired outcome, which supports the client's independence. In the introductory phase, the nurse should be gathering information regarding religious beliefs. In the terminating phase, the client may feel apprehensive about assuming independent activity or self-care. Developing the plan with activities such as assisting to a standing position to walk in the hall is completed in the introductory phase.
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The nurse cares for multiple ethnic populations. Which of the following examples best demonstrates a facility adhering to The Joint Commission requirements that healthcare workers facilitate communication with all clients?
- A. The facility requires a family member of a client who does not speak the dominant language be present to discuss healthcare issues with a health care provider and member of social service.
- B. Language dictionaries are placed in the facility library with open access for staff.
- C. The facility requests bilingual staff and community members to voluntarily provide contact information for interpreter services.
- D. The facility subscribes to an online interpreting service.
Correct Answer: C
Rationale: It is a requirement of The Joint Commission that agencies develop a system to provide aids and services to any client with literacy needs and also to provide language interpreting and translation services. The best way to demonstrate this requirement is by reaching out to staff and community members to provide personal interpreting services. It is not appropriate to require a family member, if available, to be present. The other options may be helpful in communicating with clients, but personal services are optimal.
A wound care nurse approaches a client to instruct in home care needs. In which clinical scenario would the nurse delay teaching due to learning readiness?
- A. The client says that a grandchild will be in soon.
- B. The client is eating breakfast.
- C. The client is anxious about physical therapy.
- D. The client is meeting with the priest.
Correct Answer: C
Rationale: Learning readiness pertains to the optimal time for learning. This occurs when a client is in a state of physical and psychological well-being. Being anxious about an upcoming activity distracts the client from learning. Waiting until after the activity allows the client to be more focused on the teaching. Nurses may decide to delay teaching due to visiting family, eating breakfast, and meeting with a priest, but it is not from learning readiness.
A nurse has been caring for a client and family for 6 months in a long-term care facility. Which nursing action(s) is appropriate during the terminating phase of the nurse-client relationship? Select all that apply.
- A. Teach the client and family about care needs at home.
- B. Attend to the client's preferences regarding diet.
- C. Allow the client independence in decision-making.
- D. Relay well wishes from the staff.
- E. Arrange health-related services to support home care.
- F. Coordinate medication regimen for home care.
Correct Answer: A,D,E,F
Rationale: The terminating phase occurs when the client's health problems have improved and nursing services in the long-term care facility are no longer necessary. The nurse's role becomes one that transitions the client and family to home care. Teaching about needs, arranging health-related services, and coordinating medication regimen for home care are all appropriate. Also, relaying well wishes from the staff shows the caring nature of the staff and highlights the nurse-client relationship while in the facility. Attending to the client's dietary preferences and allowing client independence in decision-making are part of the working phase of the nurse-client relationship.
The charge nurse delegates the administration of a pain medication to a practical nurse. Which statement, made by the charge nurse, indicates that the final step in the delegation process has been completed?
- A. Did you document the administration of the pain medication on the medication record?
- B. Is the physician aware of the client's need for pain medication?
- C. What is the client's pain level since administering the pain medication 30 minutes ago?
- D. Have you ever administered this type of pain medication previously?
Correct Answer: C
Rationale: The final step in the delegation process is to ensure that the task has been completed and determine the resulting outcome of the action. In this case, it is ensuring the medication is given and assessing for pain relief. The other steps may be completed in the delegation process, but they are not completed last.
A nurse is caring for a client who is newly diagnosed with cancer and receiving a peripherally inserted central catheter (PICC). Upon analysis, the nurse determines that the client is an affective learner. Which type of learning situation would the client learn from best?
- A. Having the client make a poster with the equipment from the PICC line
- B. Having the client prepare notes related to the PICC line to be discussed with the physician
- C. Having the client attend a group support meeting of people with PICC lines
- D. Having the client look online for information related to the PICC line
Correct Answer: C
Rationale: An affective learner learns best when the information is presented with consideration of the client's thoughts/feelings, values, or beliefs. Having a client attend a group support meeting with individuals having similar life struggles provides the opportunity for the client to learn how best to live with the new diagnosis and care for themselves. Making a poster with equipment is helpful for a psychomotor learner. Preparing notes and learning online is helpful for a cognitive learner.